Art and science have their meeting point in method.

 

- Bulwer-Lytton

 

 

Chapter 2

MY APPRENTICESHIP WITH AN ADHD CLINIC

 

In 1993, I was hired as a therapist by Catholic Community Ser­vices North­west (CCSNW)—a licensed outpa­tient mental health center—for the agency’s Oak Harbor Family Center. After 21 years, and a series of administrative positions, I had fi­nally returned to my bliss, children’s mental health. 

Oak Harbor is a small Navy town located on the north end of Whidbey Island, in Puget Sound.  Pic­turesque Whidbey is 45 miles long—the larger of two islands that make up rural Island County, Wash­ington.       

My assignment was to replicate the center-based ADHD clinic model that had been de­veloped by Rhoderick Elin, Ph.D. at the agency's main office in Bel­lingham, Washington.  Under Dr. Elin's tutelage, I began offering ADHD services in January 1994:  diagnostic assessments, counseling, parent education classes and a support group for parents of chil­dren with ADHD.  In the process of learning my new craft, I was to learn that I have ADD.

National recognition of the CCSNW clinics came with the publica­tion of Dr. Elin's pro­gram model in The ADHD Report[1] and an invitation to present the model at CHADD's 1994 national conference as one of twenty new innovative ADHD programs in the United States.[2]

The procedures used by the CCSNW ADHD Clinics for diagnosing ADD in chil­dren and adults are described in the remaining sec­tions in this chapter.  (The diagnos­tic process for adults is discussed in more detail.)

                          

DIAGNOSING ADD IN CHILDREN

             

How is ADD evaluated and diagnosed in children?  The procedures that Catholic Community Services follows in diagnosing childhood ADD are consis­tent with those recommended by the American Academy of Pediatrics (2000).  They include the following:

 

1.    Parent and teacher objective scales rate the child's behaviors against norms for his or her age group and gender[3];

2.    Parent completion of a questionnaire that in­cludes developmental, aca­demic, medical and social-emotional histories.

3.    A structured interview with the child and his/her parent(s) (e.g., ADHD Clinic Parent In­terview, Barkley, 1991);

4.    Observation of the child;

5.    Consultation with the child's physician to rule out possible neurological or medical causes for ADD-like symptoms;

6.    Consultation with current or former mental health therapists who have treated the child;

7.    A conference with the child's teacher(s);

8.    A review of any prior psychoeducational test­ing re­sults, Individualized Educa­tion Program (IEP) and school progress reports.

      

DIAGNOSING ADD IN ADULTS

             

The evaluation process for diagnosing ADD in adults is similar to the one out­lined for chil­dren, but it requires a detailed retrospective analysis of child­hood behavior. ADHD clinic therapists in our pro­gram do the following when com­pleting adult ADD evaluations: 

 

1.    A detailed history is the cornerstone of a good adult evaluation.  A struc­tured interview, such as Russell Barkley's Semistructured Interview for Adult ADHD (Barkley, 1991)[4], is essential for gleaning historical informa­tion.  The inter­view format in­cludes questions about prenatal and birth history; developmental milestones; medical history; aca­demic history; the per­son's social, emotional and behavioral devel­opment; and family genetic history. 

2.    CCSNW administers two types of adult ADD rating forms during the evaluation process.  My favorites are:  1) The Adult Behavior Rating Scale - Self Report of Current Symptoms and its companion form, the Self Report of Childhood Be­havior[5] is com­pleted by the client (there is also an “Other” version for spouses, friends, etc.); 2) Daniel Amen’s General Adult ADD Symptoms Checklist. 

The former rating form is normed, the latter is not.  Amen’s form, however, rounds out the list of ADD symptoms, giving a broader perspective of the disorder than the Adult Behavior Rating Scale, which rates the ADHD DSM-IV symptoms only.

3.    When feasible, the evaluator contacts the adult cli­ent's parents (preferably the person's mother) to confirm childhood information such as birth his­tory, developmental mile­stones, medical history, school progress re­ports/testing results and social-emotional de­velopment.  A parent is asked to complete the Parents' Rating Scale form, which retro­spec­tively rates ADD symptoms between the ages of six and ten years.

4.    The person's physician is consulted regarding spe­cific medical conditions that might be sig­nificant to the ADD evaluation. 

5.    Additional supplementary information may be gath­ered from the client's spouse or partner, sib­lings, friends, supervisors and past thera­pists.

6.    Other sources of client information include a men­tal status examination and the following forms: Boredom Proneness Rating Scale; the Personal His­tory Checklist - Adult; the Physi­cal Complaints Checklist for ADHD Adults; and the Self-Rating Symptom Checklist for ADHD Adults. 

(See the detailed description of each form below.)

 

 

STRUCTURING THE ADD ASSESSMENT

 

The information gathered during interviews with the client, from supplemen­tary sources, and the findings of the various behavior rating instru­ments, is structured and presented in an assessment report format I adapted for my private practice from Dr. Elin’s original ADHD clinic format.  The core data for adult assessments comes from client completion of the Personal History Checklist™ for Adults.[6]   The adult assessment report format follows:

         

Presenting Information*[7]

             

Procedures

 

Sources of information for this evaluation included individual interviews with the client, his/her parent(s), spouse or partner, work supervi­sor, professor, etc. The following documents were re­viewed:  [School re­cords, job evaluations, medical re­ports, past psy­chological reports, etc.]

             

The following forms were completed:

 

·        ADHD Behavior Checklist for Adults

·        Adult ADD Quiz

·        Boredom Proneness Rating Scale

·        General Adult ADD Symptoms Checklist

·        Locke-Wallace Marital Adjustment Test

·        Mental Status Examination

·        Parents' Rating Scale

·        Personal History Checklist™ for Adults

·        Physical Complaints Checklist for ADHD Adults

·        Self-Rating Symptom Checklist for ADHD Adults

·        Semistructured Interview for Adult ADHD

·        Wender Utah Rating Scale

·        Zuckerman Risk-Taking Quiz

 

The following items were reviewed:

 

·        Medical records

·        Mental health treatment records

·        Psychological testing results

·        School and/or college records

 

Collateral telephone contacts were made with:

 

·        X

       

ASSESSMENT SUMMARY

             

Objective Scales 

 

The following scale scores were found to be clinically signifi­cant . . . [List rating scales and scale scores.  Scale scores of +1.5 stan­dard de­viations (SD), or greater, are considered clini­cally significant for most scales.]

 

Client Strengths

 

Family Background*

 

Childhood and Adolescence*

 

Educational and Occupational History*

 

Medical History and Health*

 

Family History*

 

Current Situation*

 

 

DSM-IV ADHD DIAGNOSTIC CRITERIA

 

According to the multiple sources providing informa­tion, the client is positive for __ of nine ADHD inattentive symp­toms (six required) and __ of nine ADHD hyper­ac­tive-impulsive symptoms (six required). Symptoms onset was re­ported to be at __ years of age.

          

CONCOMITANT ISSUES

 

Differential assessment indi­cates that the client meets the DSM-IV criteria for ___ Dis­order(s) [or meets no other diagnostic criteria that ei­ther mask symp­toms of ADHD or are comorbid to his/her presenting is­sues]:             

             

SUMMARY AND CONCLUSIONS

 

From the information pro­vided, observations and behavioral scales, it would seem that the client does/does not experience At­ten­tion-Defi­cit/Hyperactivity Disorder, [list type], with con­comitant symptoms of [list other mental disor­ders].           

             

DSM-IV DIAGNOSTIC IMPRESSIONS

             

Axis I:         314.0         ADHD, Predominately Inattentive Type.

                   XXX.X        Comorbid Disorders.

 

Axis II:        799.9         Deferred [or list].

 

Axis III:      General medical conditions contributing: [list].

 

Axis IV:      Psychosocial stressors: [list].

 

Axis V:       Global Assessment of Functioning (GAF) = X

             

 

RECOMMENDATIONS

             

The following recommendations will prove of value in helping the client adjust appro­priately:

 

1.                Psychoeducation about ADHD.

2.                Participation in an adult ADHD support group.

3.                Physician consultation for a possible medica­tion trial to treat symptoms of ADHD

and comor­bid disorders.

4.                Individual, marital, or family counseling as needed for adjustment issues and/or

comor­bid disorders.

5.                Aptitude testing and career counseling.

6.                Etc.

             

 

 

ADULT ADD DIAGNOSTIC TOOLS

             

As listed above, I use the following forms and rating scales to diag­nose adult ADD:  

             

ADHD Behavior Checklist for Adults – it alter­nately lists each of the nine inat­tentive DSM-IV crite­ria with the nine hyperactive-impulsive criteria.  The adult respondent rates his or her symptoms twice:  over the past 6 months and as a child (ages 5-12 years).  Symptoms are rated by fre­quency of oc­currence:  rarely or never; sometimes; often; very of­ten.  Three scores are obtained from the answers:  an inatten­tion score; a hyperactive-impulsive score; and the to­tal score.  ADHD symptoms occurring "often," or "very of­ten," are considered endorsed.  Norms are available for the number of endorsed symptoms, both current and recalled.  Scores that equate to +1.5 standard deviations (SD) above the mean (93rd per­centile), or greater, are considered clinically significant.  Revised versions of these forms are known as, Adult Behavior Rating Scale—Self Report of Current Behavior and Adult Behavior Rating Scale—Self-Report of Child­hood Behavior (Barkley, 1997b, 1998b). 

 

Adult ADD Quiz - a list of 100 adult ADD symp­toms and risk factors.  A "yes" response endorses an item.  The quiz can be used as a "quick and dirty" screen­ing tool before the formal intake process.  No norms have been estab­lished for the quiz; it should not be used by itself to con­firm a diagnosis of ADD.  (In Hallowell & Ratey, 1994a.)

 

Amen's ADD Subtype Test - an online self-rating form that lists 58 ADD symp­toms. The respondent rates symptoms with one of the following frequency rat­ings: 0 = does not apply; 1 = rarely; 2 = some­times; 3 = often; 4 = very often.  The responses result in a determination of the person's ADD subtype ac­cording to Daniel Amen's typology.  (Online at The Amen Clinic for Behavioral Medicine @ http://www.amenclinic.com.)

 

Amen’s General Adult ADD Symptom Checklist  - com­pleted by the client or another rater.  It consists of 78 symptoms in 17 categories, including past history, short attention span/distractibility, restlessness, im­pulsivity, poor organi­zation, nega­tive internal feel­ings, relational difficulties, short fuse, frequent search for high stimulation, writ­ing/fine motor coor­dination difficulties, sleep/wake diffi­culties, low en­ergy and sensitivity to noise or touch.  Symptoms are rated as occurring never, rarely, occasion­ally, fre­quently or very frequently.  "More than 20 items with a score of three or more indicates a strong tendency toward ADD."  The fol­lowing three items are essential for a diagnosis:  history of ADD symptoms in child­hood; short attention span; the person is distracted easily.  (Online at The Amen Clinic for Behavioral Medicine @ http://www.amenclinic.com/.)

 

Boredom Proneness Rating Scale (BP) - a 28-ques­tion "true-false" instrument designed to measure a person's predilection to boredom.  It has norms for men and women.  (See Fischer & Corcoran, 1994, vol. 2.)

             

             

Copeland Symptom Checklist for Adult Atten­tion Deficit Disorders - used by the subject, or a signifi­cant other, to rate his or her inattention, im­pulsivity, overactivity, un­deractivity, noncompliance, under­achievement, emotional diffi­culties, poor peer rela­tions and impaired family rela­tions.  Behaviors are rated as occurring not at all, just a little, pretty much or very much. Each behavior is as­signed a percentage by dividing the client's total point score in each section by the total points possible in that sec­tion.  Scores between 35-49% sug­gest mild to mod­erate difficulties; scores between 50-69% sug­gest moderate to severe diffi­culties; scores above 70% sug­gest major interference.  "Undifferen­tiated ADD" (ADD/-H), as described in the DSM-III, is manifest on the Copeland by signifi­cant difficulties in inatten­tion, under­activity and underachievement.  (Published by the Southeastern Psychological Institute, P.O. Box 12389, Atlanta, GA 30355-2389.)

        

 

Parents' Rating Scale (PRS).  A parent of the adult client, preferably the mother, completes this instru­ment.  She retrospectively rates the degree of prob­lem severity for 10 symptoms experienced by her adult child between the ages of six and ten years.  Re­sponse choices are:  not at all; just a little; pretty much; very much.  (In Wender, 1995.)

           

Personal History Checklist™ for Adults - 119 items re­lated to seven areas:  pre­senting information; family background; childhood and adolescence; educational and occupational history; medical history and health; family history; and current situation.  The information can be input into a computer software program (sold separately) that compiles the data into a written report, which can be pasted into the final ADD assessment report.

            

Physical Complaints Checklist for ADHD Adults - a self-rated 17-symptom checklist.  The client rates the fre­quency of his or her physical symptoms with one of the following responses:  never; less than 4 times/year; less than once/month; less than once/week; nearly daily.  This is a good tool to screen for comorbid conditions.  (In Barkley, 1991.)

             

Self-Rating Symptom Checklist for ADHD Adults - rates the degree to which 19 psychosocial problems have oc­curred in the past week on a Lickert 10 point scale: 0 = not a problem; 10 = very severe problem.  Space is pro­vided for the client to list ad­ditional problems.  The client circles up to three as the pri­mary prob­lems.  This is another good tool to screen for comorbid conditions.  (In Barkley, 1991.)

              

Semistructured Interview for Adult ADHD - a 15-page interview form used by Russell Barkley and his colleagues at the University of Massachusetts Medi­cal Center (Barkley, 1991).  It includes sections on symptoms, school history, past psychiatric his­tory, past medical history, de­velopmental history, medica­tions, allergies, family history and social his­tory. 

             

             

Wender Utah Rating Scale  (WURS) - a retrospec­tive 61-item self-report rating scale that has the adult respondent rate childhood ADD symptoms as having oc­curred not at all or very slightly, mildly, moderately, quite a bit or very much.  Scores are normed for men and women.  (In Wender, 1995.)

           

Zuckerman Risk-Taking Quiz - a self-rated "true" or "false" instrument.  Re­spondents rate 18 state­ments, 16 of which relate to risk-taking behaviors.  Total point scores are used to calculate gender-spe­cific "risk quotients"—very low, low, average, high and very high.  (In Zuckerman, 1994.)

       

DIFFERENTIAL DIAGNOSIS

             

A differential diagnosis must be made to rule out other physical or mental conditions as the cause of an adult's ADD-type symptoms, or to determine if co­morbid disor­ders co-exist with ADD. Other mental disorders with symptoms that can mimic ADD in­clude anxiety, Asperger’s Syndrome, Bipolar Disorder, depression, Fetal Al­cohol Syndrome or Fetal Alco­hol Effects and person­al­ity disorders.[8]  Alcohol and drug abuse are quite fre­quent among adults with ADD and should be ruled out.

The following rating scales and software can be used to assess issues that are comorbid with ADD:

 

Alcohol Use Disorders Identification Test (AUDIT) - a two-part alcohol use disorders screening tool de­veloped by the World Health Organization.  Part 1, or the core AUDIT, asks 10 questions about recent al­cohol use.  A score of eight or greater on the first part identifies alcoholism with about 92% accuracy.  Part 2, the Clinical Screening Procedure, is optional.  It is administered when the cli­ent's answers on Part 1 are vague or more information is desired.  (Available online @ http://www.niaaa.nih.gov/publications/Instable.htm.)

 

Beck Depression Inventory (BDI) - a multiple-choice adult self-rating depres­sion scale consisting of 21 items.  (Available for purchase through the Psychological Corporation, 55 Academic Court, San Antonio, TX 78204.)

            

Goldberg Depression Scale & Goldberg Mania Scale - although not designed as diagnostic scales (they are used to measure the severity of symptoms), a thera­pist may use them as a screening tool to help in the diagnosis of cur­rent depres­sive or manic signs.  Each instrument is made up of 18 questions related to de­pressive or manic symp­toms.  The respondent self-rates each behavior in the past week as occur­ring not at all, just a little, somewhat, mod­erately, quite a lot or very much.  No norms are available, but high total point scores may indi­cate the need for fur­ther evaluation.   (Available online @ http://www.lorenbennett.org/goldberg.htm.)

 

Index of Drug Involvement - twenty-five questions about a respondent's drug use:  he or she rates each behavior with one of seven responses ranging from "none of the time" to "all of the time."  Scores of 25 to 175 are possible. The clini­cal cutting score is 30, above which a person is considered to have a drug abuse problem.  (See Faul & Hudson, 1997.  Available for purchase through WALMYR Publishing Company @ www. Walmyr.com/perscales.html.)

             

Locke-Wallace Marital Adjustment Test - an in­strument consisting of 15 questions that rates a per­son's level of agreement-disagreement with his or her spouse on a vari­ety of issues.  Six response catego­ries range from "always agree" to "always disagree."  The respondent rates his or her overall marital hap­piness on a scale of "very unhappy" to "perfectly happy."  Norms for adjusted and mal­adjusted indi­viduals are available.  (In Fischer & Corcoran, 2000, vol. 1.)

             

Personality Diagnostic Questionnaire, Version 4 (PDQ-4) - a 98-question self-report form used to di­agnose all ten personality disorders listed in the DSM-IV.   (A free pencil and paper version can be downloaded from ShrinkTank @ http://www.shrinktank.com/psyfiles.htm.)

            

Social Avoidance and Distress Scale (SAD) - a rat­ing scale that measures so­cial anxiety.  It consists of 28 true/false questions.  Norms are available for males and females.  (In Watson & Friend, 1969.  Reprinted in Fischer & Corcoran, 2000, vol. 2.)

 

PROMISING TECHNIQUES FOR ADD DIAGNOSIS IN THE FUTURE   

 

ADD is not yet diagnosed with medical tests, but is rapidly moving toward that goal.  The discovery of a possible ge­netic marker for an ADD gene was re­ported in 1995 by a team of researchers, led by Drs. Edwin Cook and Mark Stein, at the University of Chicago (Cook et al., 1995).  Their discovery may one day make de­finitive medical diag­nosis a reality.  The ADD marker is believed to be linked to a gene that regulates dopamine, a neurotransmitter in the brain.  The next step will be to isolate the gene, or genes, responsible for ADD symptoms.

Daniel Amen's SPECT brain imaging studies show promise.  Using SPECT, he analyzes functioning in several parts of the brain:  the limbic system; basal gan­glia; prefrontal cortex; cingulate system; and tem­poral lobes.  Amen (1999) has identified what he be­lieves to be three new types of ADD in addition to the ones defined in DSM-IV:  Limbic ADD, Overfo­cused ADD and Temporal Lobe ADD.  He postu­lates a pos­sible additional fourth type called, Ring of Fire ADD, which "may be a bi­polar equivalent."  (See the discussion of Amen's ADD subtypes in the Introduction of this book.)

             

 

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